DRAFT Revised Employment Application

APPLICATION FOR EMPLOYMENT

Date(Required)

Your Email Address(Required)

Your Name(Required)

First Middle Last

Present Address(Required)

Street Address City County State ZIP Code

Previous Address

Street Address City County State ZIP Code

Phone(Required)

Referred by:

Driver's License No. and State

May we contact your present employer?(Required)

Yes

May we contact your previous employer?(Required)

Yes

Position(s) for which you are applying:(Required)

Date you can start:(Required)

Rate of pay desired: $(Required)

per:(Required)

EMPLOYMENT APPLICATION CERTIFICATION

Employment application certification(Required)

I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application or provided in the hiring process including but not limited to any preliminary screening applications, applications completed or information submitted or provided to Big Bend Community Based Care, Inc. d/b/a NWF Health Network (NWFHN) which is discovered at any time after I am employed may result in my dismissal.

I hereby authorize NWFHN to investigate all statements contained in this application and to interview the references and previous employers listed in this application. I authorize the references and previous employers listed to give NWFHN all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such parties from any liability which may allegedly arise from furnishing such information to NWFHN including, but not limited to, any liability for defamation or invasion of privacy. If I am offered employment by NWFHN I understand that such an offer will be conditioned upon satisfactory results of a background investigation, reference checks and/or agency medical examination or inquiry, including a drug screen test. If then employed, I understand that I will be required to serve a probationary period. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my probationary period, at the option of either my employer or myself. I understand that no supervisor or other employer representative other than the CEO has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by NWFHN to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in my immediate dismissal.

I certify that I have read, understand, and agree with the above.

Applicant Signature:(Required)

Date:(Required)

Comments

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